The nurse is admitting a client who has not slept in three days to the inpatient care facility. The client has pressured speech and describes an increase in sexual promiscuity. Which problem should the nurse include in the client's plan of care?

Disturbed personal identity.

Risk for injury.

Ineffective coping.

Anxiety, panic.

Answer and Explanation

The Correct Answer is B

A) Disturbed personal identity could be relevant in the context of a mental health issue, but it is not the most immediate concern given the client's current presentation. While it may be important to address over time, it does not take precedence in the acute phase.

B) Risk for injury is the most critical problem to include in the client's plan of care. The client's lack of sleep, pressured speech, and increase in sexual promiscuity indicate a potential manic episode, which can lead to impulsive and unsafe behaviors. Prioritizing the risk for injury ensures the safety of the client and others, making it essential for the immediate care plan.

C) Ineffective coping is a concern that may develop in response to the client's current symptoms. However, addressing immediate safety needs is more urgent than focusing on coping mechanisms at this point.

D) Anxiety and panic might be present, but they are not as clearly defined in the client's current symptoms as the risk for injury. The focus should remain on preventing harm and ensuring the client is safe during this acute episode.

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Correct Answer is B

Explanation

A) Haloperidol is an antipsychotic that may be used for agitation or hallucinations, but it is not the first-line treatment for alcohol withdrawal symptoms. Administering haloperidol without addressing withdrawal may not be effective and could lead to further complications.

B) Lorazepam is a benzodiazepine and is the preferred medication for managing alcohol withdrawal symptoms, including agitation, anxiety, and hallucinations. It helps reduce the risk of severe withdrawal symptoms and seizures while providing sedative effects. Given the client’s symptoms of feeling bugs crawling on his body, which may indicate tactile hallucinations due to withdrawal, lorazepam would be the most appropriate choice.

C) Diphenhydramine is an antihistamine that can be used for allergic reactions or as a sedative, but it is not effective for managing alcohol withdrawal symptoms.

D) Thiamine is important to prevent Wernicke's encephalopathy in clients with a history of alcohol dependency, especially if there are signs of confusion or neurological deficits. However, it does not address the immediate symptoms of withdrawal the client is experiencing.

A. Impaired comfort. B. Risk for injury. C. Ineffective breathing pattern. D. Ineffective coping.

Correct Answer is C

Explanation

A) Impaired comfort is a relevant concern, but it is not the highest priority in the context of a potentially life-threatening situation such as aspiration of a caustic material. While comfort is important, it is secondary to immediate safety and physiological needs.

B) Risk for injury is a general concern in many situations, but in this specific case, it does not address the acute medical implications of the aspiration of caustic material. While injury could occur, the focus should be on the immediate effects of the incident.

C) Ineffective breathing pattern is the highest priority nursing problem. Aspiration of caustic material can lead to severe respiratory complications, including airway obstruction, chemical pneumonitis, and other respiratory distress. Ensuring the client has adequate ventilation and monitoring for signs of respiratory distress are critical nursing interventions that take precedence over other concerns.

D) Ineffective coping is important to address, particularly given the context of a suicide attempt; however, it is not as immediate as the potential life-threatening consequences of aspiration and ineffective breathing. The client’s physical safety must be prioritized before addressing psychological issues.

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The nurse is admitting a client who has not slept in three days to the inpatient care facility. The client has pressured speech and describes an increase in sexual promiscuity. Which problem should the nurse include in the client's plan of care?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client is admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt. Which nursing problem has the highest priority?

Correct Answer is C

Explanation

The healthcare provider prescribes lithium carbonate for a client diagnosed with bipolar, manic depression. It is most important for the nurse to review which laboratory finding prior to beginning the drug therapy?

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During admission to the psychiatric unit, a female client is extremely anxious and expresses that she is worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?

A client with somatic symptom disorder reports experiencing chest pain to the nurse. Which action should the nurse take?

The nurse is admitting a client who has not slept in three days to the inpatient care facility. The client has pressured speech and describes an increase in sexual promiscuity. Which problem should the nurse include in the client's plan of care?